CODING WITH Q-Codes

Q-Codes User Guide

Clinical and managerial activities

Coding with Core Content Classification in General Practice/Family Medicine means identifying the main concepts the writer is willing to share in a text. This is called ‘text classification’ or ‘topic list building’ in computer sciences and ‘qualitative data analysis’ in cognitive sciences. Naturally, as in all coding process, only part of the reality is the object of an in-depth analysis, just like this image of the Mucem, in Marseille, where you just can imagine the landscape through the grid of the architectural wall..

For the sake of the exercise , let’s say the GP is dealing with issues concerning the patient and with issues concerning the management of the job. Symptoms, diagnosis and process are up to what we will call clinical activities. General management as well as ethical or quality related issues are up to what we will call non-clinical or managerial activities.

Clinical activities will be identified in the text by the use of the International Classification of Primary Care second edition, electronic, version 5 (ICPC-2 e ver5). All information about coding with ICPC 2 is available on the web site of the Wonca International classification Committee and will be addressed here succinctly.

Managerial activities will be identified in the text by the use of the Q-Codes, version 2.1, 2015 which which will now be explained in details.

Coding clinical activities with ICPC-2

ICPC-2 has been intended to identify the health problems along the contact between patient and doctor before the plain informatics age and has been surprisingly well adapted to the Electronic Medical Record and related activities like external link to EBM database. Here we are using it to identify the clinical (ie symptoms, diagnosis, process) in the communication. Understanding in deep ICPC-2 coding is beyond this user guide. ICPC-2 desk copy in A4 format is available for download on the Kith website in a lot of languages, here is a link to the English one. ICPC has a structure. Searching for ICPC could be done also on the HETOP web site by choosing the tab ICPC-2. Alternatively the Dutch WHO-FIC center edit a ICD10/ICPC2 search facility (WHO-FIC standing for World Health Organization – Family of International Classifications). Downloading the last ICPC version i.e. ICPC-2 e Ver 5 is a must. This version includes a description of the content of the usual process in Primary Care.

Coding medical texts with ICPC could raise some difficulties. First of all ICPC is fit only for prevalent problems and rare diseases are identified by the .99 digit. GPs are pleased to describe rare diseases they have discovered or studied in depth and it is sometimes frustrating to identify ex ; “Primary Pulmonary Amyloidosis” (Wonca Kos 2005) by the code R99. Nevertheless this kind of presentation is pretty rare. It is more often the Process code that has to be used. Indeed GPs like to address drug related problems, and the code *50 (drug prescription) is consequently usual. See the list of process code..

Secondly, GPs use frequently lay expressions like Chronic diseases or Infectious diseases. It will be impossible to identify the concept at stake in a communication about for instance ‘Chronic disease burden in GP/FM’. This kind of expression is definitely too vague and covers extended fields of work. The very fact that ICPC-2 has no, unlike ICD, special chapter for Cancer could also be a problem. In ICPC “the cancers” is a not existing expression. Cancers are related to each body chapter. A title like “long term survivor of cancer in GP/FM” could be identified by the concept “survivor” (Q-Codes QC6) but not the item “cancer”.

Communications and grey literature abstracts.

A good abstract has to be structured with the classical division ; Title , aim or intro, method; results, discussion. This rule is sometimes mandatory but often not respected and leads to difficulties in discovering what is at stake. It could be illustrated as searching for a needle in a haystack. You get the overall impression you understand. After starting to read the whole abstract, you realize the author is confused and merges method and results or aims and results. Some authors are conflating the title with the announce of their results (e.g. in Wonca, 2007 ‘The prevalence of asthma in rural areas in Crete is similar to that of urban areas’). Some other authors use enigmatic title, as in ‘Feasibility of a clinical database and accompanying evidence base’(Ibid.) or ‘Easily avoided…CVA – A Case report’ or ‘NICEly filling in the gaps’(Wonca 2010). Acronym in a title are always a sign of belonging to an identified group, showing some kind of internal slang which symbolizes the link between the author and a cast of professionals. Who else indeed than a colleague of the author could understand: “Bearing uncertainty: diagnosis of CHD in a low prevalence setting”(ibid.)? One would have to go further in the abstract, reading at least the aim and the method.

Going deeper allows you to widen the keyhole and have a better insight in the subject. Identification of the main subject is needed. If the subject is identified, you consider the aim. As an example this title “Profile of the use of psycho-pharmaceuticals for elderly patients in Vereador Durval Costa Basic Unit of Health Care” gives you several pieces of information. This is firstly about prescription of drugs in the psychological domain, secondly it also talks about the elderly. You have to assume that Vereador Duval Costa is a place or a name but the case deals with Primary care setting. Thus the coding will be P for Psychological chapter of ICPC, *50 for the process of prescription. Elderly has its place in Q-Codes and you chose QC13. Finally Primary care setting is QS1. Thus, only with the title, the coding sequence is P / *50 / QC13 / QS1. But you fail to understand the methodology of this study. You are obliged to go back to the abstract and read ; “This study deals with drugs. The study has as general objective to describe the prevalence” […],The present work is treated of a study epidemiological transverse sectional with quantitative analysis”(sic). Now you know that it is an epidemiological study in primary care (Q-Codes ; QR2 ) using a cross sectional methodology (Q-Codes : QR42).

Now you understand the picture. You can clearly see the subject and admire the museum of photography in Charleroi, Belgium, the abstract speaks about some interesting matter for you.

Indeed you understand that the full title would have been ; “Cross sectional epidemiological study in a basic unit of health care; psychiatric drug prescription for elderly in Vereador Durval Costa” of which the full coding process would be ;

QR2 epidemiology of primary care

QR42 cross sectional study

QS1 primary care setting

P Psychological

*50 Drug prescription

QC15 Elderly

Interestingly, knowing the codes, you could perfectly make a reverse coding. After some essays you will observe that R deals with Research, S with Structure, C with category of patient. P is psychological and *50 deals with drugs.Only with the first letter of the domains, you know that the abstract deals with Research (R) in a Structure (S) for a Category of patient (C) and drug prescription (*50) in the psychological field (P)

Some exercises

The exercises quoted here are extracted of the coding process of the abstracts in a meeting of Swiss GPs in 2014. Don’t pay attention to the codes themselves as they have been slightly changed. The coding version used here is Q-Codes version 2.0. Now the ongoing version is Q-Codes version 2.1. Nevertheless, the point is to be able to identify in the text what the GPs are discussing and what the main issues are. You see that only titles, aims and methods are presented here. Indeed there is no interest in coding results and discussion. You have to take in account that the interest is to develop a database of knowledge in GP/FM. So it makes sense to be able to retrieve all the abstract dealing for instance with Quality assurance or with Primary prevention. This could lead to a network of researchers for instance or make easier the attendance to a congress.

The software of Qualitative analysis ATLAS.ti has been used here to identify more easily the concepts. Any CAQDAS software could fit for this kind of qualitative analysis.

Naturally, if you try to codes new abstracts, you will be confused because some important items are missing in the Q-Codes ver2.2. There are now 182 operational codes but the analysis has been performed on European congress communications. Moreover the intend is not to affirm GP/FM has to feel concerned as in an expert top-down move. The project is to make a bottom-up approach by identifying the main subjects addressed by GPs currently working. Thus if you can’t find the relevant codes, use QO (other) to identify them and share your data and comments to take an active part in the elaboration of your tool and prepare the next Q-codes version.

I am interested in any comment, remarks, note, disagreement, suggestion or proposal for better definitions. New Q-Codes entry suggestion is welcome providing it comes from analysis of enough amount of Primary Care Providers communications . The suggested theme has to be really prevalent in the PCP community and not yet part of existing Q-Codes. Then it will be considered as a potential QO4 (Consider new code) for next version. Candidate will be considered providing sources are transmitted (abstracts, thesis etc)